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Episode 8 : Smoking Part 2: Steps to Take to Quit Smoking

Release Date: December 8, 2006

Dr. David Meyerson: Hi, I'm Dr. David Meyerson, cardiologist at Johns Hopkins and your host for this edition of Vascular Disease Foundation's HealthCast. The Vascular Disease Foundation is made up of organizations widely known as premiere health education groups throughout the country and HealthCast is brought to you as a public service.

We have had the wonderful benefit of talking to Dr. Susan Bartlett. She's an Associate Professor of Medicine a Health Psychologist at Johns Hopkins. She is a smoking cessation expert and, in fact, she is one of those people at Johns Hopkins who actually teaches doctors in training how to get their patients to stop smoking. Today's episode is really where the rubber meets the road. How five ways, five key ways for smoking cessation. If you are a smoker, if you have someone that you love that you want them to stop smoking, you want to assist them the best way you possibly can do that, this is the program for you to listen to. We have brought Dr. Susan Bartlett back by special acclaim because our first program in this regard was so interesting and really hardly scratched the surface, so Dr. Susan Bartlett, thank you so much for coming back to the HealthCast microphones.

Dr. Susan Bartlett: Indeed my pleasure to be back.

Dr. David Meyerson: We talked about the magnitude of a problem with smoking that there is no product in the United States that is currently sold, except cigarettes when used as directed; it is still guaranteed to be harmful. And I use the analogy of, if a seven-forty-seven jetliner full of passengers, three hundred and fifty people crashed, it would be on every news program. If two planes crashed they would, they would stop, they would ground the entire fleet, three a Senate investigation, and four there are the equivalent of four seven-forty-sevens full of passengers dying every single day directly attributable to tobacco smoking. This is a terrible public health issue. We want our patients to stop smoking. There is a benefit to quitting no matter how long you have smoked. Doctor Bartlett let's get started, let's give our listeners the tools, five key steps to smoking cessation. Where do you want to start?

Dr. Susan Bartlett: Let me start again by just reiterating how big of a challenge stopping smoking is. You know if you've never smoked, it's really easy to look at smokers and say, "Gosh all they need to do is quit." But the truth is, if you're addicted, and we believe many people are highly addicted even within the first week of smoking. If you're addicted, you found the perfect drug. If you're tired and you needed a little bit more energy, have a cigarette. It'll make you more alert. On the other hand, if you're all wound-up and stressed and you need to relax yourself, have a cigarette. The nicotine will calm you down.

Dr. David Meyerson: My brother used to smoke. My brother used to smoke and he would tell me - because I never did fortunately, although I smoked a quarter of a cigarette when I was twelve in my parents' basement, and I turned all kinds of colors, and fortunately my body told me, I was very lucky to get that message. But he told me, he said, "David, you will never appreciate the combination of a cigarette and a cup of coffee in the morning to get everything going in the right direction." And it took him years and years to stop. One of the things you told us in the last episode that I thought was so important, and

I'd like you to repeat that. You said that people who quit successfully, generally, generally are not successful the first time around. They should not be considering themselves failures or bad people. This is a tough addiction.

Dr. Susan Bartlett: It takes an average of five serious attempts for people to successfully stop smoking. And we'll talk about that in a couple of minutes. I think one of the things that happens is each time you quit, and then you go back to it, you learn some very important information about yourself, which you can use in the next quit attempt. But I would like to encourage every listener out there if you've made serious quit attempts, and you're still smoking, don't give up, this doesn't mean you can't quit smoking. What this means is you're just that much closer to ultimately being successful. Let's go back to the five things that you need to do to get ready to quit. The first thing is to actually prepare yourself. One of the most effective things you can do is to set a quit date. Now, a quit date should not be set today, or tomorrow. Ideally, the quit date would be sometime in the next three weeks or so.

Dr. David Meyerson: Get yourself ready in advance.

Dr. Susan Bartlett: Get yourself mentally ready.

Dr. David Meyerson: How about your loved ones? You have to get them ready too.

Dr. Susan Bartlett: Give them a chance to get used to the idea that you're going to be a nonsmoker. To think about some of the changes that they may need to make to support your not smoking anymore. You're going to have to look at your environment very carefully. What you want to do is get rid of all cigarettes. You know, don't stop smoking and have half a carton still sitting on the refrigerator.

Dr. David Meyerson: So get rid of the stashes, get them out of your desk drawer, get them out of your purse, get them out of the night stand. Just get rid of them.

Dr. Susan Bartlett: Get rid of the ashtrays too. Get rid of anything that's going to remind you, and make sure that you don't let people smoke around you. Let them know that it's very important that they not smoke, for instance, in your car, in your home, at your work place. It's also a great idea to think about what happened the last few times that you tried to stop smoking, because you know, the best predictor of future behavior is past behavior.

Dr. David Meyerson: Where did I fail last time?

Dr. Susan Bartlett: Where did I run into some trouble? Wherever you ran into trouble in the past, that's going to be a real high risk situation for you at this quit attempt. So think about those previous quit attempts. You know, was it the fact that you still went out with friends, and you went for a few drinks at the bar, and there was all that smoke around you, that made you well, have that first cigarette? Was it the fact that you were trying to change too many things at once? You decided that you would stop smoking, and start running, and eat a healthy diet.

Dr. David Meyerson: And be afraid about gaining weight as you did that?

Dr. Susan Bartlett: Absolutely. So think about what worked and what didn't work, and then make a firm promise to yourself that once you quit on your quit date, you will not have another cigarette, not even one puff. That's so, so important.

Dr. David Meyerson: Do you tell them to think about their social plans, and avoid situations where people would be more apt to smoke?

Dr. Susan Bartlett: Well, absolutely, and in fact that brings us to step two. Step two is garner the support and encouragement that you can from your friends and family. You know, friends and family offer social support, which is an invaluable resource and it's there just for the asking. Tell your family, and friends, and your coworkers that you're going to quit, and you'd like to have their support, and ask them not to smoke, or not to offer you a cigarette. You may even want to say to them, "You know if I have that weak moment, and I say just give me one. I'm asking you right now to look at me and say, `No.'"

Dr. David Meyerson: Be strong for me.

Dr. Susan Bartlett: You're doing really well. Right.

Dr. David Meyerson: And you got to let them know, I'm going to be ornery for a couple of three weeks. You've got to get me through this. I'm going to rely on you to help. I'm going to shoulder the burden myself, but please don't get angry at me if you see my behaviors changing a little bit. It's going to be worth it on the other end.

Dr. Susan Bartlett: Absolutely. And tell your doctor as well. Your doctor is going to be thrilled that you're making this attempt.

Dr. David Meyerson: Oh, ecstatic. When my patients tell me they're stopping, or cutting – even cutting down, and we talked about, cutting down isn't as good as stopping. You really do have to stop. Cutting down, as I said in the last time was like saying I'm only going to drive a hundred thirty-five miles an hour two days a week. So you're going to run off the road on a Tuesday, or a Saturday, or something. So, I'm so excited to hear excellent smoking cessation advice. What would be the next step?

Dr. Susan Bartlett: Well, talk with your doctor about whether or not nicotine replacement products may be useful for you. And we'll talk about that a little bit more in a few minutes. But that's where talking with your healthcare provider can be very important because, if the decision is made to use nicotine patches, for instance, you'll want to make sure you have those patches before your quit date. You're not going to use it before your quit date, but you want to have them on hand. And for instance, if you use one of the medications that's been associated with higher success rates with smoking cessation, you'll need to get that script and get it filled.

Dr. David Meyerson: Would Wellbutrin be one of those?

Dr. Susan Bartlett: That's the drug that I'm talking about. Step three is learn some new skills, and some new behaviors. One of the most important things you're going to have to be able to do is to distract yourself. You're going to have urges to smoke, and they are going to be very, very powerful. And you're going to have to find a new way to deal with it.

Dr. David Meyerson: But the urges, you told us only last a certain amount of time.

Dr. Susan Bartlett: The urges seem to peek and then diminish in about ten minutes or so.

Dr. David Meyerson: So if you project, I have to occupy myself. I have to absolutely protect myself for those ten, or twelve, or fourteen minutes, then you can get over that hump, and move on to the next thing that you need to do.

Dr. Susan Bartlett: Absolutely. What I don't suggest anyone does is just sort of sit there and try to muscle your way through it. For instance, let's say, you're sitting there at your desk at work, and you really want a cigarette, you want one badly. The ideal thing would not be to just sit there and say, "No I'm not going to have a cigarette, I'm not going to have a cigarette." Instead, distract yourself by getting up and doing something. Go over and talk to somebody, take a little walk, take a break. Anything that you can do that's going to change your routine at the moment you're having that intense craving is going to be helpful.

Dr. David Meyerson: Do you ever recommend that somebody have a friend that knows that they're stopping smoking, and just be honest, and call them up on the telephone and say, "Gees, you know I'm really having an urge now, I need you to talk me down." Do you ever do that?

Dr. Susan Bartlett: Well, I find that my female patients say that that actually works very well for them. For many of my male patients, I don't think they tend to feel as comfortable doing that, but hey if it works, you know, anything that works, I'm in favor of bringing into your arsenal, because you've got quite a fight on your hands. We also know that you're going to feel stressed just by the process of stopping smoking. So anything that you can do that helps relax yourself, warm baths, nice long walks, reading a book, doing some hobbies or activities. Anything that lowers your overall level of stress, especially in first two weeks is going to be very helpful. And, your body is going to go through a tremendous change, your going to go through acute nicotine withdraw. It's very important to drink lots of fluids, water in particular, to help flush out so many of the metabolites. So keep you water up, keep your physical activity up, have many different ways to be able to distract yourself, have those skills and those behaviors at your disposal so that when you do have those cravings, and you will without question, that you know how to respond in a new way. The old way was picking up a cigarette, now you want to have a toolbox full of a number of different ways you can respond.

Dr. David Meyerson: So let's move on now to those people -- once we have the behavioral parts, once we have the family support, once we've set our quit date, once we've gotten the cigarettes out of our desk drawers, and our purses and our night stand, the cigarettes, the ashtrays, the matches, the lighters, they're all gone. We have maybe the dish of sugar free candies available to us. What then do we do if we think we need additional help? You talked about some pharmacologics, some medicines, some replacement therapies. Can we talk a little bit about the nicotine patch?

Dr. Susan Bartlett: Absolutely. Because basically we would suggest that anybody who's smoking more than ten cigarettes a day, absolutely if you're smoking a pack a day. You are physiologically addicted. Now what nicotine replacement is going to do is it's going to replace a little bit of the nicotine in your body, and we hope that's going to make the withdraw a little less severe.

Dr. David Meyerson: Now my best recollection when I read there were patches at different nicotine replacement levels, and my understanding was that you had one level for a period of time, and then you drop down to the next level, then you drop down to the next level, and off. Is twenty-one, fourteen, and seven? Is that still a valid way to go, or are there better way to use nicotine patches?

Dr. Susan Bartlett: Well, I'll tell you what I tell my patients. Those stepped approaches are a terrific marketing idea, but the reality is people tend to use the patches in this way. They put on the patch, they use it for one to two weeks, and they're over the rough spot, and they don't use the rest of it. So what we suggest is get the strongest dose. Even the strongest dose of nicotine patch is just a drop in the bucket compared to what you're getting from one cigarette. Just one cigarette. So you're only getting a very small percentage. I can't state that often enough, because it's really important in terms of setting up expectations. A lot of people believe if they put the patch on, they won't crave cigarettes. Nothing could be further from the truth. You are still going to have incredibly strong cravings, but maybe you won't have insomnia quite as bad. Maybe the muscle cramping won't be as difficult. Maybe the feeling, just feeling out of sorts, we can take the edge off of that with the nicotine replacement.

Dr. David Meyerson: So you're taking down the withdrawal symptoms at the same time that you're breaking the habit of picking up that neural groove that you talked about, that cause you to pick up the cigarette and light it. So you're breaking that pattern of behavior, substituting something else and I wonder, have you ever heard of the two patch technique for smoking cessation? What we've been told is that you take one patch and put it over each eye and then you can't find your cigarettes. Do not do that. That is a lame attempt at this host's humor. We only use the patches as directed, but in any event, that is a very valuable adjunct. So you say, we don't have to go through that six or eight weeks program of stepping down. You use them for two weeks and then what do you do, just stop abruptly?

Dr. Susan Bartlett: That's what most people do. That's the way they do it. Now, that's not to say that the six-week approach wouldn't be perhaps more optimal --

Dr. David Meyerson: Uh-huh [affirmative].

Dr. Susan Bartlett: -- but the reality is most people don't do it.

Dr. David Meyerson: Now when they say that the patches are expensive, fact of the matter is if you smoke two packs a day for a week -- I guess we're talking about seventy or eighty dollars worth of cigarettes in a week. Patches can't be half that, is that right?

Dr. Susan Bartlett: Well, patches are between say forty and fifty dollars a week and that is a lot of money.

Dr. David Meyerson: Uh-huh [affirmative].

Dr. Susan Bartlett: I mean, it's a whole lot of money to come up with all at once. It, I'm sure, gives many people reason to pause.

Dr. David Meyerson: But people can be spending five thousand dollars a year on cigarettes.

Dr. Susan Bartlett:  Well, the thing that I think is --

Dr. David Meyerson: Imagine just a couple hundred dollars on patches, what a deal.

Dr. Susan Bartlett: But if I said to you, there's something that you can do that will basically double the likelihood that you're going to be successful this time, would you do it?

Dr. David Meyerson: Absolutely.

Dr. Susan Bartlett: That's the patch. So, it's really important and it's really very helpful if you understand how it works. Many people will put a patch on while they're still smoking thinking that, well, this will help me not want to smoke. Nothing could be further from the truth.

Dr. David Meyerson: And dangerous.

Dr. Susan Bartlett: Absolutely because all you're doing is then adding more nicotine to your system. So what happens is, you stop smoking tonight and once you stop smoking and have committed to yourself, you're not going to have another cigarette, then you put the patch on. So, very important never smoke and have the patch on at the same time. You really do want to talk to your doctor if you're smoking more than a pack a day because it may be that you need more than one patch.

Dr. David Meyerson: Uh-huh [affirmative].

Dr. Susan Bartlett: Under those circumstances, you really need some medical monitoring too.

Dr. David Meyerson: What about the nicotine gum? Is that a successful way to do that? It actually gives something to do orally with which cigarettes also do.

Dr. Susan Bartlett: You know, the nicotine gum has been around for probably fifteen years and in fact, it's every bit as effective as the patch. Most people will tell you they've tried it and it didn'twork. The reason it didn't work is because they didn't use it the way it's designed.

Dr. David Meyerson: They just used it as a substitute for a cigarette for any craving, right?

Dr. Susan Bartlett: Well, no.

Dr. David Meyerson: And not as a cessation tool.

Dr. Susan Bartlett: No. A little bit more than that. It's unfortunate that it was called gum, because in fact, gum is misnomer and it should not be treated as gum. So there is --

Dr. David Meyerson: That was just a vehicle to get the nicotine into your system.

Dr. Susan Bartlett: That's right, right. And the way that that works is -- and by the way, the nicotine gum is about one third the cost of the patches, so -- and you can put patches and gum together, that's fine. You can use up to twenty pieces of gum a day with the patch. The way to use the gum, once again once you've stopped smoking. You can't be smoking while you do this. But you take it, you put it in your mouth and you chew it for about ten seconds or so. You just want to soften it up and expose more of the surface area. Now take that piece of gum and park it in the back of your mouth against your cheek.

Dr. David Meyerson: Behind a molar like when you were in grade school.

Dr. Susan Bartlett: That's right. That's when you're absorbing nicotine, only when it's parked against your cheek. If you're chewing it, what you're doing is you're releasing nicotine and it's going into your stomach where all it's going to do is irritate your stomach. But you leave it parked in your cheek for about ten minutes, take it out, chew it two or three more times, expose more surface area, park it again. Do that a third time and after thirty minutes, you've basically extracted all of the nicotine from the gum so you can get rid of it at that point. What you don't want to do is put it in your mouth and just chew because you basically will get very little benefit and probably a stomachache out of it.

Dr. David Meyerson: Can you use the other medicines that we talk about to help the irritability along with the patches, such as the Wellbutrin that you mentioned earlier?

Dr. Susan Bartlett: Well, about thirty percent of people who smoke, we think do so because nicotine actually has some pretty impressive antidepressant affects. And so once you stop the nicotine, you can feel quite low and quite depressed for a couple of weeks. For individuals who really struggle with mood changes and feeling very uncomfortable, noticing that they're short tempered, those are individuals that probably would do well by accompanying the patch with one of the medications. Now the medication that has been tested for smoking cessation and proven to work is Wellbutrin. Actually when it was first released, and the name is slipping from my mind -- it's available in another form that we used to suggest would be used, exactly the same prescription. There are three different forms of Wellbutrin and it doesn't seem to matter which of the versions that you use. In fact, quite honestly, it's probably not that Wellbutrin is that much different from any anti-depressant, but it was the one that was studied. It was one that the drug manufacturer invested the money to study.

Dr. David Meyerson: So at least we have proof in hand that it is of some value.

Dr. Susan Bartlett: Absolutely. Now, for Wellbutrin to work, what needs to happen is, you need to start that ten days before your quit date. So you want to have it at therapeutic levels.

Dr. David Meyerson: That's important. Can you repeat that? I want people to hear that because you told me, for example, when you're going to stop quitting, you made a plan and you set a date and now -- and you're saying with the Wellbutrin, with pharmacologic therapy, you want to get that in your system well before you actually quit smoking.

Dr. Susan Bartlett: In contrast to nicotine replacement, like the patches that you will not use until you've stopped, you want the Wellbutrin in your body. That's why going to your doctor in advance, talking about this, deciding together if Wellbutrin may be helpful is very useful because you can get started on the Wellbutrin.

Dr. David Meyerson: And as a cardiologist, I will tell you a patient comes to me saying, "Doctor, I am motivated to stop smoking." I am in their corner one hundred and twenty-three percent.

Dr. Susan Bartlett: When you put buproprion which is the Wellbutrin, and the patch and possibly the gum together, you have the strongest, most effective arsenal to help the patient stop smoking. So for anyone who's smoking a pack or more a day, that's really where my recommendations go. And you know the Wellbutrin has another very important benefit. It seems to forestall weight gain. As long as you're taking Wellbutrin, you're not going to gain weight. This is so important for women because the number one reason that women either don't make a quit attempt or go back to smoking is because they see their weight change and they see it change in five pounds in three weeks.

Dr. David Meyerson: I've heard that countless times from my patients and I often say, "You know, from a health perspective, I would much rather see you stop smoking and I will then help you deal with the weight, but stopping smoking is the critical key to preventing further disease."

Dr. Susan Bartlett: So if you're a woman and you're really worried about your weight, then definitely speak with your doctor about getting on the Wellbutrin.

Dr. David Meyerson: Let me ask you this because we only have two minutes left, Dr. Bartlett. Is there a website that you know of or some sort of source where somebody could look up something about smoking cessation if they wanted to get a little bit more than we've been able to give them during this episode?

Dr. Susan Bartlett: Probably one of the very best sources is the National Cancer Institute website and that's If you simply type smoking cessation into google, you'll get wonderful resources. The other thing I want to mention is the National Cancer Institute also has a quit line. I think the quit line is staffed from eight in the morning until seven at night by trained nurses who are experts in helping you to stop smoking. It's free. You give them a call, it's an eight hundred number and they'll walk you through all of these steps that we've just been talking about.

Dr. David Meyerson: My special guest today has been Dr. Susan Bartlett, Associate Professor of Medicine, a Health Psychologist at Johns Hopkins, a smoking cessation expert and with enormous gratitude, this is a critical public health issue. It remains a critical public health issue. From the Vascular Disease Foundation, we beg you, if you are a smoker, there is probably nothing that you could do to add more years to your life and increase your functional capacity long-term than stopping smoking. This is also a gift of enormous value that you can give to a loved one. For Vascular Disease Foundation, I'm Dr. David Meyerson, till next time, have a great day.


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